Gait, propulsive [Festinating gait]
Propulsive gait is characterized by a stooped, rigid posture — the patient’s head and neck are bent forward; his flexed, stiffened arms are held away from the body; his fingers are extended; and his knees and hips are stiffly bent. During ambulation, this posture results in a forward shifting of the body’s center of gravity and consequent impairment of balance, causing increasingly rapid, short, shuffling steps with involuntary acceleration (festination) and lack of control over forward motion (propulsion) or backward motion (retropulsion). (See Identifying gait abnormalities, pages 286 and 287.)
Propulsive gait is a cardinal sign of advanced Parkinson’s disease; it results from progressive degeneration of the ganglia, which are primarily responsible for smooth muscle movement. Because this sign develops gradually and its accompanying effects are usually wrongly attributed to aging, propulsive gait commonly goes unnoticed or unreported until severe disability results.
History and physical examination
Ask the patient when his gait impairment first developed and whether it has recently worsened. Because he may have difficulty remembering, having attributed the gait to “old age” or disease processes, you may be able to gain information from family members or friends, especially those who see the patient only sporadically.
Also, obtain a thorough drug history, including medication type and dosage. Ask the patient if he has been taking tranquilizers, especially phenothiazines. If he knows he has Parkinson’s disease and has been taking levodopa, pay particular attention to the dosage because an overdose can cause an acute exacerbation of signs and symptoms. If Parkinson’s disease isn’t a known or suspected diagnosis, ask the patient if he has been acutely or routinely exposed to carbon monoxide or manganese.
Begin the physical examination by testing the patient’s reflexes and sensorimotor function, noting abnormal response patterns.
Medical causes
Parkinson’s disease
The characteristic and permanent propulsive gait begins early as a shuffle. As the disease progresses, the gait slows. Cardinal signs of the disease are progressive muscle rigidity, which may be uniform (lead-pipe rigidity) or jerky (cogwheel rigidity); akinesia; and an insidious tremor that begins in the fingers, increases during stress or anxiety, and decreases with purposeful movement and sleep. Besides the gait, akinesia also typically produces a monotone voice, drooling, masklike facies, a stooped posture, and dysarthria, dysphagia, or both. Occasionally, it also causes oculogyric crises or blepharospasm.
Other causes
Drugs
Propulsive gait and possibly other extrapyramidal effects can result from the use of phenothiazines, other antipsychotics (notably haloperidol, thiothixene, and loxapine) and, infrequently, metoclopramide and metyrosine. Such effects are usually temporary, disappearing within a few weeks after therapy is discontinued.
Carbon monoxide poisoning
A propulsive gait commonly appears several weeks after acute carbon monoxide intoxication. Earlier effects include muscle rigidity, choreoathetoid movements, generalized seizures, myoclonic jerks, masklike facies, and dementia.
Manganese poisoning
Chronic overexposure to manganese can cause an insidious, usually permanent, propulsive gait. Typical early findings include fatigue, muscle weakness and rigidity, dystonia, resting tremor, choreoathetoid movements, masklike facies, and personality changes. Those at risk for manganese poisoning are welders, railroad workers, miners, steelworkers, and workers who handle pesticides.
Special considerations
Because of his gait and associated motor impairment, the patient may have problems performing activities of daily living. Assist him as appropriate, while at the same time encouraging his independence, self-reliance, and confidence. Advise the patient and his family to allow plenty of time for these activities, especially walking, because he’s particularly susceptible to falls due to festination and poor balance. Encourage the patient to maintain ambulation; for safety reasons, remember to stay with him while he’s walking, especially if he’s on unfamiliar or uneven ground. You may need to refer him to a physical therapist for exercise therapy and gait retraining.
Pediatric pointers
Propulsive gait, usually with severe tremors, typically occurs in juvenile parkinsonism, a rare form. Other possible but rare causes include Hallervoden-Spatz disease and kernicterus.
Book Source Details
- Book Title: Handbook of Signs & Symptoms (Third Edition)
- Author(s): Springhouse
- Year of Publication: 2006
- Copyright Details: Handbook of Signs & Symptoms (Third Edition), Copyright © 2006 Lippincott Williams & Wilkins.
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Copyright Details: Handbook of Signs & Symptoms (Third Edition), Copyright © 2008 Williams & Wilkins.
More About Causes of Walking symptoms
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